GA2-64
Hemodynamic Compromise During Rod Placement For Posterior Spinal Fusion In A Patient With Pectus Excavatum
Mamdani F, Mangat G, Lee K
New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, USA
INTRODUCTION: Pectus excavatum (PE) is a benign congenital anterior chest wall deformity. In many cases, the presence of PE does not increase an individual’s morbidity or mortality, and is primarily repaired for cosmetic reasons. The prevalence of scoliosis in PE patients is about 23% and these patients may present for scoliosis repair (1). We describe a case of hemodynamic compromise in a patient with unrepaired PE during a posterior spinal fusion surgery.
CASE DESCRIPTION: A 15 year old boy with a history of PE, Marfan’s syndrome, aortic root dilatation replacement, AICD placement for episodes of ventricular tachycardia, and scoliosis presented for posterior spinal instrumentation and fusion (PSIF). After an uncomplicated anesthesia induction, a central line and arterial line were placed. The AICD was deactivated and zoll pads placed. The patient was positioned prone and remained hemodynamically stable. Positioning ensured no external pressure was placed on the PE. During placement of surgical screws and osteotomies at T6-L3 levels, the mean arterial pressure (MAP) was maintained above 70 mmHg with phenylephrine boluses and infusion.
As placement of the rod for correction began, the MAPs acutely dropped to the 30s and improved when surgical manipulation was stopped. Norepinephrine infusion was initiated and fluid was given. Once the MAP stabilized, spinal correction was reattempted. The MAP again dropped but improved when manipulation was paused. Cardiology and general surgery were consulted intraoperatively. Hemodynamic instability was thought to be due to compression of the heart and/or greater vessels as curvature correction further lessened the intrathoracic space with the PE deformity. The procedure was aborted with the decision to reattempt after pectus repair. The patient was transported to the ICU intubated on minimal pressor support. Postoperative CT chest showed severe PE deformity causing compression of the right heart and overall leftward shift. The patient underwent an uncomplicated open PE repair and a PSIF two weeks later. He tolerated the procedure well without any hemodynamic instability, and recovered well postoperatively.
DISCUSSION: Because it is considered a benign condition, physicians may not consider the potential hemodynamic effects in patients with PE. A few case reports have described hemodynamic compromise with prone positioning in these patients (2-4). Using echocardiography, these reports identified right ventricular compression that led to a decrease in preload. In our case, CT chest performed after initial surgery revealed severe deformity that caused right ventricular compression in the supine position, which was further exacerbated by prone positioning, particularly with spinal manipulation. We add to the growing body of proof that pectus patients should have preoperative imaging, including a CT and cardiac studies, to assess compromise and possible repair prior to other surgeries that can add additional stress.
REFERENCES:
1. Hong JY, et al. J Ped Ortho. 2011; 31: 870-4.
2. Bafus B, et al. J Spinal Disord Tech. 2008; 21: 451-4.
3. Galas J, et al. Congenit Heart Dis. 2009; 4:193–5.
4. Alexianu D, et al. Anesth Analg. 2004; 98: 334–5.
Top
